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1.  Dramatic resolution of bullous pemphigoid after surgery for gastric cancer: A case report 
INTRODUCTION
An association between bullous pemphigoid (BP) and internal malignancy has been suggested. However, no reports have documented a dramatic improvement in BP after surgery for gastric cancer.
PRESENTATION OF CASE
An 82-year-old Japanese woman was admitted to a local hospital for severe fatigue. On examination, she was diagnosed with BP and gastric cancer. Her BP was resistant to steroid treatment; however, it improved dramatically after surgery for gastric cancer.
DISCUSSION
In this case, a strong relationship appeared to exist between BP and gastric cancer.
CONCLUSION
This is the first report of a dramatic improvement in BP after surgery for gastric cancer.
doi:10.1016/j.ijscr.2014.02.008
PMCID: PMC3980412  PMID: 24675083
BP, bullous pemphigoid; CRP, C-reactive protein; Resolution; Bullous pemphigoid; Gastric cancer
2.  Hepatic angio-sarcoma: An unusual source of intra-hepatic bleeding☆ 
INTRODUCTION
Hepatic angio-sarcoma represents an uncommon malignant tumor of the liver with a poor prognosis and a high rate of bleeding complications.
PRESENTATION OF CASE
We report a case of hepatic angio-sarcoma with a multi-nodular pattern complicated by intra-hepatic bleeding. The diagnosis was performed by computed tomography (CT). Angiographic procedure was unsuccessfully attempted as a treatment option. Autoptic examination confirmed the vascular nature of the malignant tumor.
DISCUSSION
Hepatic angio-sarcoma represents the most common malignant mesenchymal tumor of the liver. The diagnosis is provided by the histological examination and by specific endothelial markers. However, CT examination allows to recognize the disease and to detect intra-abdominal bleeding occurring in one-fourth of cases. Surgical resection represents the only definitive treatment of hepatic angio-sarcoma. In case of haemoperitoneum, trans-catheter arterial embolization represents the primary procedure used to stop the acute arterial bleeding.
CONCLUSION
CT represents the reference technique for the diagnosis of hepatic angio-sarcoma and allows to recognize the intra-abdominal bleeding which represents its most common complication. This condition always requires an immediate therapeutic approach.
doi:10.1016/j.ijscr.2013.12.007
PMCID: PMC3980516  PMID: 24646944
Hepatic angio-sarcoma; Computed tomography; CT; Bleeding; Angiography
3.  Assessing the complications and effectiveness of open carpal tunnel release in a tertiary care centre in a developing country 
INTRODUCTION
Open surgical release for carpal tunnel syndrome is not devoid of complications and its quantitative assessment with the Boston questionnaire in a developing country had not been conducted, where, lack of facilities and surgical technique can influence the outcome.
PRESENTATION OF CASE
This was a prospective study in which all cases of carpal tunnel syndrome undergoing open release between June 2007 and June 2012 and who returned for follow up were included. Each patient was requested to fill out the Boston questionnaire twice both pre and post op at 3 months. All complications were recorded as well as bio-data of patients and co morbidities. Follow up was at 2 weeks and at 3 months. Those reporting complications at 3 months were further followed up until 6 months. 373 patients were included in the study. Twenty four patients developed complications. Of these, 12 experienced pain resulting from reflex sympathetic dystrophy. Three patients developed wound dehiscence, 2 cases acquired infections, 4 patients developed immediate post-operative haemorrhage and in 3 patients there was late recurrence of median nerve compression. The symptom severity score pre-operatively was 3.30 (±0.60) and it improved to 1.65 (±0.75) post-operatively indicating a significant change (p < 0.0001). The preoperative functional status score was 2.58 (±0.75) and post-op it became 1.60 (±0.80) again implying a good improvement with an effect size of 1.3.
DISCUSSION
All of the complications produced were well managed. The complication incidence was low. The open release procedure produced good improvement in hand function and in decreasing the symptom severity.
CONCLUSION
Conducting open release for carpal tunnel syndrome in a tertiary referral centre in a developing country offers a good outcome.
doi:10.1016/j.ijscr.2014.02.007
PMCID: PMC3980520  PMID: 24667074
Carpal tunnel syndrome; Complication; Median nerve; Boston questionnaire
4.  Osteoclastic giant cell tumor of the pancreas☆ 
INTRODUCTION
Pancreatic giant cell tumors are rare, with an incidence of less than 1% of all pancreatic tumors. Osteoclastic giant cell tumor (OGCT) of the pancreas is one of the three types of PGCT, which are now classified as undifferentiated carcinoma with osteoclast-like giant cells.
PRESENTATION OF CASE
The patient is a 57 year old woman who presented with a 3 week history of epigastric pain and a palpable abdominal mass. Imaging studies revealed an 18 cm × 15 cm soft tissue mass with cystic components which involved the pancreas, stomach and spleen. Exploratory laparotomy with distal pancreatectomy, partial gastrectomy and splenectomy was performed. Histology revealed undifferentiated pancreatic carcinoma with osteoclast-like giant cells with production of osteoid and glandular elements.
DISCUSSION
OGCT of the pancreas resembles benign-appearing giant cell tumors of bone, and contain osteoclastic-like multinucleated cells and mononuclear cells. OGCTs display a less aggressive course with slow metastasis and lymph node spread compared to pancreatic adenocarcinoma. Due to the rarity of the cancer, there is a lack of prospective studies on treatment options. Surgical en-bloc resection is currently considered first line treatment. The role of adjuvant therapy with radiotherapy or chemotherapy has not been established.
CONCLUSION
Pancreatic giant cell tumors are rare pancreatic neoplasms with unique clinical and pathological characteristics. Osteoclastic giant cell tumors are the most favorable sub-type. Surgical en bloc resection is the first line treatment. Long-term follow-up of patients with these tumors is essential to compile a body of literature to help guide treatment.
doi:10.1016/j.ijscr.2014.01.002
PMCID: PMC3980420  PMID: 24631915
Giant cell; Pancreas; Osteoclastic; CEA, carcinoembryonic antigen; cGy, centigray; CT, computerized tomography; GCT, giant cell tumor; MV, megavolts; OGCT, osteoclastic giant cell tumor; PD, pancreaticoduodenectomy; PR, pancreatic resection; PGCT, pleomorphic giant cell tumor; RFA, radio frequency ablation; RT, radiotherapy
5.  Direct inguinal hernia containing bladder carcinoma: A case report and review of the literature☆ 
INTRODUCTION
Inguinal hernia containing bladder carcinoma is a very rare occurrence.
PRESENTATION OF CASE
We report a case of a male patient who presented with a left groin hernia containing an irregular mass. The hernia was repaired without the use of mesh and a partial cystectomy was done.
DISCUSSION
Only 1–3% of all inguinal hernias involve the bladder, with very few reports containing a carcinoma.
CONCLUSION
Treatment consists of removing the tumor and repairing the hernia.
doi:10.1016/j.ijscr.2014.01.007
PMCID: PMC3980519  PMID: 24632299
Inguinal hernia; Bladder carcinoma
6.  Epstein–Barr virus positive inflammatory pseudo-tumour of the spleen: A case report and literature review☆ 
INTRODUCTION
Epstein–Barr virus positive inflammatory pseudo-tumour (IPT) of the spleen is an uncommon, frequently asymptomatic entity, which is typically picked up as an incidental finding on imaging.
PRESENTATION OF CASE
We present a case of EBV positive IPT of the spleen which presented as an incidental finding on CT in a patient with a history of malignancy. Splenectomy was performed.
DISCUSSION
IPTs are benign spindle cell lesions of varying aetiology, which can arise in a variety of tissues, including the spleen. In situ hybridisation showed strong staining for Epstein–Barr virus RNA in our case, in common with many similar lesions described in the literature. The differential diagnosis of such spindle cell tumours is discussed.
CONCLUSION
Radiologically, EBV positive spindle cell tumours are indistinguishable from malignant lesions such as lymphoma and diagnosis is made on histology, usually at splenectomy.
doi:10.1016/j.ijscr.2013.12.006
PMCID: PMC3980515  PMID: 24632301
Inflammatory pseudotumour; Epstein–Barr virus; Follicular dendritic cell tumour
7.  A novel endoscopic treatment of major bile duct leak☆ 
INTRODUCTION
Bile leak is a serious complication of hepatobiliary surgery. The incidence has remained the same over the last decade despite significant improvement in the results of liver surgery.
PRESENTATION OF CASE
A 21-year-old man was a passenger in a motor vehicle and sustained a blunt abdominal trauma in a high-speed collision leading to major liver laceration. He had right lobe hepatectomy complicated by major bile leak. He was not fit for further surgery and he, therefore, had ERCP and obliteration of the leaking bile duct using a combination of metallic coil and N-butyl cyanoacrylate.
DISCUSSION
Endoscopic therapy has become the modality of choice in the treatment of biliary tract injuries. Different modalities of management of persistent bile leak such as sphincterotomy, plastic biliary stents, and nasobiliary drainage have been described. Obliteration of bile duct leak using N-butyl cyanoacrylate and coil embolization has been described but most of these reports used the percutaneous transhepatic approach.
CONCLUSION
In this paper, we describe the second reported case in English literature of a novel endoscopic technique using a combination of metallic coil embolization and N-butyl cyanoacrylate in a patient with major bile leak who was not a candidate for surgery as well as a third report of the late complication of coil migration to the common bile duct.
doi:10.1016/j.ijscr.2014.01.017
PMCID: PMC3980414  PMID: 24636979
Liver resection; Bile leak; ERCP; Metallic coil; N-butyl cyanoacrylate
8.  Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned☆ 
INTRODUCTION
The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst.
PRESENTATION OF CASE
We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS.
DISCUSSION
HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis.
CONCLUSION
Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.
doi:10.1016/j.ijscr.2014.01.020
PMCID: PMC3980419  PMID: 24636980
Hepatic cyst; Rhabdomyosarcoma; Choledochal cyst
9.  Breast metastases from a Renal Cell Carcinoma. A case report and review of the literature☆ 
INTRODUCTION
Metastases to the breast from extra-mammary tumors are uncommon and few sporadic cases are reported in the international literature. An accurate differential diagnosis of secondary cancer is mandatory because both prognosis and treatment differ with respect to primary breast tumors.
PRESENTATION OF CASE
We present the case of a 70-year-old woman with an isolated metastasis to the breast occuring 9 years after undergoing a nephrectomy for Renal Cell Carcinoma (RCC).
Clinical examination revealed a palpable and mobile mass in the right breast with an enlarged ipsilateral axillary lymph node. Mammographic findings showed a dense, well circumscribed solid mass and the breast ultrasonography findings were those of a hypoechoic homogeneous solid nodule with no posterior attenuation but with prominent peripheral vascularity. A tru-cut biopsy was conclusive for a metastatic deposit by RCC. A whole-body CT scan showed no evidence of further recurrences. The patient underwent metastasectomy and exeresis of the papable lymphnode.
DISCUSSION
In patients with former surgery for RCC, a diagnosis based on a preoperative biopsy allows to indicate the proper surgical treatment: in facts, as compared to primary breast tumors treatment, the rationale to pursue wide surgical margins is pointless in cases of metastases and, similarly, the biopsy of the sentinel lymphnode is void of sense due to the lack of its physiopathological prerequisite.
CONCLUSION
We suggest to consider a micro-histological biopsy of any new breast lesion appearing in a patient with a history of treatment for RCC. Prompt diagnosis is necessary to choose the right treatment.
doi:10.1016/j.ijscr.2014.01.019
PMCID: PMC3980508  PMID: 24632302
Renal Cell Carcinoma; Diagnosis; Breast metastases
10.  Salpingo-ureteric fistula—A rare complication following laparoscopic surgery for colorectal cancer: A case report and literature review☆ 
INTRODUCTION
We report the management and outcome of the case of a 57-year old woman with adenocarcinoma of the rectum. Following neo-adjuvant chemo-radiotherapy and laparoscopic-assisted anterior resection of her tumour she developed a right salpingo-ureteric fistula.
PRESENTATION OF CASE
Three weeks following laparoscopic anterior resection of the tumour she presented with urinary frequency and incontinence. A ureteric stent was inserted and left in-situ for five months but the fistula did not heal. The patient underwent exploration and open repair of the salpingo-ureteric fistula which resolved her symptoms.
DISCUSSION
There have not been many reported cases in the literature of salpingo-ureteric fistulae but after initial trial of management with ureteric stents all eventually required open exploration and repair.
CONCLUSION
we advocate open repair of salpingo-ureteric fistulae as the definitive management following intra-operative injury.
doi:10.1016/j.ijscr.2014.01.021
PMCID: PMC3980517  PMID: 24636981
Salpingo-ureteric; Complication; Fistula; Fallopian tube; Colorectal cancer; Laparoscopic
11.  Urological vignette: Satellite lesion in the bladder from urachal enteric adenocarcinoma☆ 
INTRODUCTION
We present, to the best of our knowledge, the first published case report of a satellite lesion within the bladder from enteric type urachal adenocarcinoma (UA).
PRESENTATION OF CASE
Our case report involves a 38-year-old man from the Solomon Islands who underwent open partial cystectomy for UA. However, resection margins were positive due to the novel finding of a satellite lesion on histopathological assessment. Salvage cystectomy was subsequently performed and the patient had an uncomplicated post-operative recovery.
DISCUSSION
This case highlights the importance of achieving negative soft tissue and bladder margins on initial resection of UA, as the consequences of incomplete resection can place significant additional morbidity on the patient.
CONCLUSION
We aim to highlight the possibility of satellite lesions within the bladder in UA and suggest that further studies looking at this phenomenon are required to establish its incidence and overall impact on management of UA.
doi:10.1016/j.ijscr.2014.01.014
PMCID: PMC3955229  PMID: 24556377
Cystectomy; Urachal adenocarcinoma; Urinary bladder neoplasms
12.  Idiopathic hypertonicity as a cause of stiffness after surgery for developmental dysplasia of the hip☆ 
INTRODUCTION
There are various complications reported with surgical treatment of DDH. Most studied complication is avascular necrosis of the femoral head and hip stiffness. The purpose of this report was to describe a case with severe stiffness of the hip due to hypertonicity in periarticular muscles after it was treated for developmental dysplasia of the hip (DDH).
PRESENTATION OF CASE
Three-year-old patient referred to our institution with bilateral DDH. Two hips were operated separately in one year with anterior open reduction, femoral shortening osteotomy. Third month after last surgery, limited right hip range of motion and limb length discrepency identified. Clinical examination revealed that patient had limited range of motion (ROM) in the right hip and compensated this with pelvis obliquity. Gluteus medius, sartorius and iliofemoral band release performed after examination under general anesthesia. Symptoms were persisted at 3rd week control and examination of the patient in general anesthesia revealed full ROM without increased tension. For the identified hypertonicity, ultrasound guided 100 IU botulinum toxin A injection performed to abductor group and iliopsoas muscles. Fifth month later, no flexor or abductor tension observed, and there was no pelvic obliquity.
DISCUSSION
Stiffness as a complication is rare and is usually resolved without treatment or simple physical therapy. Usually it is related with immobilization or surgery associated joint contracture, and spontaneous recovery reported. Presented case is diagnosed as hip stiffness due to underlying local hypertonicity. That is resolved with anesthesia and it was treated after using botulinum toxin A injection.
CONCLUSION
Hypertonicity with hip stiffness after surgical treatment of DDH differ from spontaneous recovering hip range of motion limitation and treatment can only be achieved by reduction of the muscle hypertonicity by neuromuscular junction blockage.
doi:10.1016/j.ijscr.2014.01.012
PMCID: PMC3955227  PMID: 24568944
Idiopathic hypertonicity; Hip stiffness; Hip dysplasia
13.  Upper cervical spinal cord gunshot injury without bone destruction☆☆☆ 
INTRODUCTION
This report describes a rare case of the gunshot injury of the spine and spinal cord.
PRESENTATION OF CASE
A rare case of the bullet lodged intra-durally in the upper cervical region without damaging the vertebrae or the spinal cord. The bullet was removed as microneurosurgical and duraplasty was performed.
DISCUSSION
Surgical management of the gunshot wounds of the spine and spinal cord is not widely advocated and controversial.
CONCLUSION
Advances in microneurosurgical instrumentation and microscopic techniques may open up a new era of surgical treatment of spinal cord gunshot wounds.
doi:10.1016/j.ijscr.2014.01.009
PMCID: PMC3955240  PMID: 24566426
Upper cervical spine; Gunshot injury; Bullet
14.  A case of xanthogranulomatous cholecystitis suspected to be adenocarcinoma based on the intraoperative peritoneal washing cytology☆ 
INTRODUCTION
Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. XGC remains difficult to distinguish from gallbladder cancer radiologically and macroscopically.
PRESENTATION OF CASE
A 63-year-old female was referred to our hospital because of a gallbladder tumor. Abdominal CT and MRI revealed a thickened gallbladder that had an obscure border with the transverse colon. FDG-PET showed a high uptake of FDG in the gallbladder. Therefore, under the preoperative diagnosis of an advanced gallbladder cancer with invasion to the transverse colon, a laparotomy was performed. Because adenocarcinoma was suspected based on the intraoperative peritoneal washing cytology (IPWC), cholecystectomy and partial transverse colectomy were performed instead of radial surgery. However, the case was proven to be XGC with no malignant cells after the operation.
DISCUSSION
In patients with gallbladder cancer who underwent surgery in our institute from 2000 to 2009, the prognosis after the operation of patients with only positive IPWC tended to be better than that of patients with definitive peritoneal disseminated nodules. It is true that in some cases, it is difficult to differentiate XGC from gallbladder carcinoma pre- and intra-operatively.
CONCLUSION
Surgical procedures should be selected based on the facts that there are long-term survivors with gallbladder cancer diagnosed with positive IPWC, and that some patients with XGC are initially diagnosed to have carcinoma by IPWC, as was seen in our case.
doi:10.1016/j.ijscr.2014.01.011
PMCID: PMC3955237  PMID: 24531017
Xanthogranulomatous cholecystitis; Gallbladder cancer; Peritoneal lavage cytology
15.  Port site and peritoneal metastases after robot-assisted radical prostatectomy☆ 
INTRODUCTION
Port site metastasis after minimally invasive urologic surgery is a rare event despite the widespread utility of laparoscopic techniques in the management of urologic malignancies. Herein, we report a case of port site metastasis after robot-assisted radical prostatectomy.
PRESENTATION OF CASE
A currently 77-year-old male patient, who was diagnosed with cT2c, Gleason 7 (4 + 3) prostate adenocarcinoma in our clinic back in 2009, had undergone robot-assisted radical prostatectomy elsewhere. Histopathological examination revealed pT3a, Gleason 9 (4 + 5) disease. Lymph nodes were negative, however surgical margins were positive on the right side. PSA recurred after 9 months and maximal androgen blockade was initiated. Despite antiandrogenic manipulations, PSA reached 0.83 ng/ml, 33 months postoperatively. Concurrently, we noticed a palpable anterior abdominal mass which demonstrated metabolic hyperactivity on PET scanning. Percutaneous biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. PSA did not normalize after the complete excision of the metastatic focus. Repeated PET scan revealed multiple implants on the peritoneal surfaces of various organs.
DISCUSSION
Port site and peritoneal metastasis of prostate cancer after robot-assisted radical prostatectomy has not been reported so far. This peculiar dissemination pattern is most probably the result of tumor biology and perioperative factors.
CONCLUSION
Although encountered extremely rarely, surgeons should be aware of the possibility of port site and/or peritoneal metastases after minimally invasive radical prostatectomy.
doi:10.1016/j.ijscr.2014.01.010
PMCID: PMC3955239  PMID: 24531016
Port-site; Metastasis; Robot; Radical prostatectomy
16.  Blood bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass☆ 
INTRODUCTION
Bowel obstruction is a known complication after bariatric surgery especially Roux-en-Y gastric bypass. The known etiologies include internal hernia, jejunojejunostomy stricture, ileus, intussusceptions, superior mesenteric artery syndrome, incarcerated port site hernia, and adhesions. Blood bezoar is a rare cause of small intestinal obstruction after Roux-en-Y gastric bypass.
PRESENTATION OF CASE
We are going to present two cases of small bowel obstruction after Roux-en-Y gastric bypass due to blood bezoar.
DISCUSSION
Blood clot as the etiology of small bowel obstruction after Roux-en-Y gastric bypass is an unusual event. In the presence of postoperative small intestinal obstruction an obstructive blood bezoar should be in differential diagnosis. As any other etiology of postoperative obstruction it should be treated immediately to prevent its adverse lethal complications.
CONCLUSION
The best way for prevention of blood bezoar is prevention of bleeding at staple line and doing hemostasis at stapler line.
doi:10.1016/j.ijscr.2013.12.022
PMCID: PMC3980510  PMID: 24632300
Bezoar; Roux-en-Y gastric bypass; Bowel obstruction
17.  Intrarectal negative pressure system in the management of open abdomen with colorectal fistula: A case report☆ 
INTRODUCTION
To present the management of open abdomen with colorectal fistula by application of intrarectal negative pressure system (NPS) in addition to abdominal NPS.
PRESENTATION OF CASE
Twenty-year old man had a history of injuries by a close-range gunshot to the abdomen eight days ago and he had been treated by bowel repairs, resections, jejunal anastomosis and Hartman's procedure. He was referred to our center after deterioration, evisceration with open abdomen and enteric fistula in septic shock. There were edematous, fibrinous bowels and large multiple fistulas from the edematous rectal stump. APACHE II, Mannheim Peritoneal Index and Björck scores were 18, 33 and 3, respectively (expected mortality 100%). After intensive care for 5 days, he was treated by abdominal and intrarectal NPS. NPS repeated for 5 times and the fistula was recovered on day 18 completely. Fascial closure was facilitated with a dynamic abdominal closure system (ABRA) and he was discharged on day 33 uneventfully. There was no herniation and any other problem after 12 months follow-up.
DISCUSSION
Management of fistula in OA can be extremely challenging. Floating stoma, fistula VAC, nipple VAC, ring and silo VAC, fistula intubation systems are used for isolation of the enteric effluent from OA. Several biologic dressings such as acellular dermal matrix, pedicled flaps have been used to seal the fistula opening with various success. Resection of the involved enteric loop and a new anastomosis of the intestine is very hard and rarely possible. In all of these reports, usually patients are left to heal with a giant hernia. In contrast to this, there is no hernia in our case during one year follow up period.
CONCLUSION
Combination of intra and extra luminal negative pressure systems and ABRA is a safe and successful method to manage open abdomen with colorectal fistula.
doi:10.1016/j.ijscr.2014.01.006
PMCID: PMC3955241  PMID: 24584042
Negative pressure; Colorectal fistula; Dynamic closure; Open abdomen
18.  Schistosomiasis as a rare cause of recurrent acute appendicitis – A case report☆ 
INTRODUCTION
We are presenting a case of schistosomiasis in a 41 year old lady who presented with right iliac fossa pain for 3 years. The pain worsened and the frequency increased in the last 3 months prior to referral. The ultrasound was unremarkable. Her bowel habits were normal and there was no vomiting. There was no blood in the stool or in the urine.
PRESENTATION OF CASE
The abdomen was soft except on deep palpation. There was slight tenderness in the right lower quadrant. A repeat ultrasound was unremarkable. The full blood count was within the normal range. A diagnosis of recurrent acute appendicitis was made and an interval appendicectomy was performed.
DISCUSSION
Histopathology results revealed schistosomiasis of the appendix. There was no acute inflammation but there was fibrous obliteration of the distal lumen of the appendix and reactive lymphoid hyperplasia.
CONCLUSION
This is the first case in a country with relatively clean drinking water. There are no irrigation schemes but there are seasonal rivers and streams. The patient admits to swimming in these streams during childhood. Clinical features of schistosomiasis were not elicited.
doi:10.1016/j.ijscr.2014.01.008
PMCID: PMC3955228  PMID: 24566427
Acute appendicitis; Schistosomiasis
19.  Pedicled omental and split skin graft in the reconstruction of the anterior abdominal wall☆ 
INTRODUCTION
The POSSG is a pedicled graft based on either the right or left gastro-epiploic arteries. It is used with a dual mesh in reconstruction of full thickness defects of anterior abdominal wall and covered by skin grafts.
PRESENTATION OF CASE
A recurrent malignant peripheral nerve sheath tumor (MPNST) of the anterior abdominal wall was excised leaving a large defect. The POSSG was used for reconstruction. A large dual mesh was placed to close the defect in the abdominal wall by suturing it to the remnant rim of abdominal muscles. The omental pedicle was brought through a keyhole in the mesh, spread out over the mesh, sutured and covered by split skin grafts. The final graft take was 90 percent.
DISCUSSION
The POSSG can be used to reconstruct any size of anterior abdominal wall defects due to the malleable nature of omentum. Its prerequisite however is a dual mesh like PROCEED. The POSSG helps keep the more complex musculofasciocutaneous flaps as lifeboats. It can be used singly where multiple musculofasciocutaneous flaps would otherwise have been required. It can be used in patients with poor prognosis of underlying malignancy. It may be used by general surgeons due to familiarity with anatomy of the relevant structures and lack of need for microsurgical skill.
CONCLUSION
The POSSG can be used in reconstruction of abdominal wall defects of any size by general surgeons.
doi:10.1016/j.ijscr.2013.12.027
PMCID: PMC3955235  PMID: 24566428
Pedicled omental flap (POSSG); Split skin graft; Dual mesh; Anterior abdominal wall; Reconstruction
20.  Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy☆ 
INTRODUCTION
Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system.
PRESENTATION OF CASE
A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely.
DISCUSSION
Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure.
CONCLUSION
In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.
doi:10.1016/j.ijscr.2014.01.005
PMCID: PMC3955231  PMID: 24531018
Laparoscopic cholecystectomy; Hemobilia; Pseudoaneurysm; Right hepatic artery
21.  Retrograde Thyroidectomy: A Technique for Visualization and Preservation of the External Branch of Superior Laryngeal Nerve☆ 
INTRODUCTION
The external branch of the superior laryngeal nerve (EBSLN) should be identified during thyroidectomy to prevent injury and post-operative voice change. Identification is rendered difficult during a standard thyroidectomy where there is a large gland with upper pole enlargement. We describe the retrograde thyroidectomy technique to facilitate nerve preservation.
PRESENTATION OF CASE
A retrograde thyroidectomy was performed in a 53-year old woman with a difficult goiter. Operative steps are described.
DISCUSSION
This technique allows the upper pole to be completely mobilized caudally providing unparalleled visualization of the upper pole vascular pedicle, thereby preserving the EBSLN.
CONCLUSION
There is better visualization of the superior thyroid pedicle and the EBSLN with retrograde thyroidectomy, potentially reducing the incidence of EBSLN injury during a difficult thyroidectomy.
doi:10.1016/j.ijscr.2014.01.001
PMCID: PMC3955232  PMID: 24514007
Thyroidectomy; Ligament of Berry; Voice; Hoarseness; Recurrent laryngeal nerve
22.  Breast ecchymosis: Unusual complication of an antidepressant agent☆ 
INTRODUCTION
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that is safely used for treatment of psychosomatic disorders. Despite being associated with a low side effect profile, it has been reported to cause hematological side effects including vaginal bleeding, epistaxis, purpura, hematuria, intracranial bleeding, and rectal bleeding. Isolated breast ecchymosis is one of exceedingly rare SSRI-induced hematological abnormalities.
PRESENTATION OF CASE
In this case study, we report a case of left breast ecchymosis in a 75-year-old woman that developed in conjunction with use of the SSRI fluoxetine.
DISCUSSION
The use of SSRIs has surged over the past decades due to increased diagnosis and focus on clinical management of depression and anxiety disorders, especially in developed nations. The low side effect profiles of the eight currently marketed SSRI agents has further promoted their use in the general population. While the most commonly reported side effects are mild and relatively tolerable, a risk of SSRI-related abnormal bleeding exists and may represent a life-threatening side effect. The most frequent SSRI-related bleeding manifestation is ecchymosis, but cases of isolated breast ecchymosis are exceedingly rare and to date only one report of SSRI-induced breast ecchymosis is included in the publicly available literature.
CONCLUSION
Three factors may have played a role in lack of reports describing SSRI-induced breast ecchymosis in literature. First, SSRIs indeed very seldom cause breast ecchymosis; second, physicians are not aware of such a causal relationship; and third, physicians find this side effect not worth to publish.
doi:10.1016/j.ijscr.2014.01.004
PMCID: PMC3955233  PMID: 24548990
Fluoxetine; Breast; Ecchymosis
23.  A very rare case of duodenal hemolymphangioma presenting with iron deficiency anemia☆ 
INTRODUCTION
Intraabdominal lymphangiomas account for less than 5% of all lymphangiomas and small intestinal hemolymphangioma is a very rare benign tumor.
PRESENTATION OF CASE
Here we describe the first case of primary ulcerated duodenal hemolymphangioma in a 24-year-old woman, causing occult bleeding from gastrointestinal tract. She presented with an unexplained refractory iron-deficiency anemia and gastroduodenoscopy revealed an ulcerated and polypoid lesion of the second portion of the duodenum. Partial resection of the duodenum was thus performed and the final pathological diagnosis was hemolymphangioma.
DISCUSSION
There were only two reports, one of a hemolymphangioma of the pancreas invading to the duodenum and another of a small intestinal hemolymphangioma, presenting with gastrointestinal bleeding until May 2012.
CONCLUSION
The aim of this case report is to highlight the difficulty in making an accurate preoperative diagnosis and describe the surgical management of an unusual location for a very rare tumor. To arrive at a definitive diagnosis and exclude malignancy, partial resection of the duodenum was considered to be the required treatment.
doi:10.1016/j.ijscr.2013.12.026
PMCID: PMC3955236  PMID: 24503337
Hemolymphangioma; Small intestine; Duodenum; Occult gastrointestinal bleeding; Anemia
24.  Living donor liver transplantation with replacement of vena cava for Echinococcus alveolaris: A case report☆ 
INTRODUCTION
There is no medical treatment for alveolar echinococceal disease (AED) of liver till now. Curative surgical resection is optimal treatment but in most advanced cases curative resection can’t be done. Liver transplantation is accepted treatment option for advanced AED. AED in some case invade surrounding tissue especially inferior vena cava (IVC). Advanced AED with invasion to IVC can be treated with deceased liver transplantation. Although living donor liver transplantation is very difficult to perform in patients with advanced AED with resected IVC, it come into consideration, since there is very few cadaveric liver.
PRESENTATION OF CASE
Here we present a case with advanced stage of AED of liver which cause portal hypertension and cholestasis. AED invaded surrounding tissue, right diaphragm, both lobes of liver and retrohepatic part of IVC. Invasion of IVC forced us to make resection of IVC and reconstruction with cryopreserved venous graft to reestablish blood flow. After that a living donor liver transplantation was done.
DISCUSSION
Curative surgery is the first-choice option in all operable patients with AED of liver. Advanced stage of AED like chronic jaundice, liver abscess, sepsis, repeated attacks of cholangitis, portal hypertension, and Budd-Chiari syndrome may be an indication for liver transplantation. In some advanced stage AED during transplantation replacement of retrohepatic part of IVC could be done with artificial vascular graft, cadaveric aortic and caval vein graft.
CONCLUSION
Although living donor liver transplantation with replacement of IVC is a very difficult operation, it should be considered in the management of advanced AED of liver with IVC invasion because of the rarity of deceased liver.
doi:10.1016/j.ijscr.2014.01.003
PMCID: PMC3955224  PMID: 24584043
Living donor liver transplantation; Echinococcus alveolaris; Inferior vena cava
25.  Oversized pseudocysts of the spleen: Report of two cases☆ 
INTRODUCTION
Pseudocysts of the spleen are usually asymptomatic and associated with a history of trauma, infection or infarction. In this report, we present two uncommon cases of solitary, oversized pseudocysts of the spleen.
PRESENTATION OF CASE
Two patients (cases A and B), with symptoms of abdominal pain, were investigated. The laboratory and ultrasound examination confirmed the diagnosis of a large, non-parasitic splenic cyst in both cases. Computed tomography described an oversized pseudocyst occupying almost the entire splenic parenchyma in both cases and in patient A, the cyst was located in the splenic hilum. The medical history revealed a previous abdominal injury only in case A. The two patients underwent an open total splenectomy. The pathology examination verified the diagnosis of a non-parasitic splenic pseudocyst.
DISCUSSION
Both patients presented with symptoms, in contrast to the majority of patients with splenic cysts. The medical history of patients with splenic pseudocysts does not always reveal the cause of the pseudocyst formation. Any type of spleen-sparing procedure is not easy to perform in cases of surgical and anatomical difficulty, because of recurrence and the risk of intractable bleeding from the spleen.
CONCLUSION
Partial splenectomy is the recommended method for parenchymal preservation, but total splenectomy is preferred when the splenic cyst is oversized or cannot be excised with safety.
doi:10.1016/j.ijscr.2013.11.006
PMCID: PMC3921642  PMID: 24463562
Non-parasitic splenic cyst; Pseudocyst of the spleen; Splenectomy; Solitary pseudocyst; Oversized pseudocyst

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